Urology Residency Training - URO-2 (PGY 3) Rotations: Overton Brooks VA Medical Center 6 months and LSU University Hospital 6 months

Transcription

1 COMPETENCY-BASED GOALS AND OBJECTIVES FOR UROLOGY RESIDENT EDUCATION [Adapted (with modifications) from: Objectives For Urology Residency Education 5 th Ed. 2001, SUU And ACGME s Outcomes Project]] Urology Residency Training - URO-2 (PGY 3) Rotations: Overton Brooks VA Medical Center 6 months and LSU University Hospital 6 months NOTE: Goals and objectives from the preceding years (PGY 1&2) should be refined, reinforced, and further developed. In addition, this year of education and training should focus on the following specific goals and objectives: I. Observe through interactions with fellow residents and supervising, attending physicians the daily practice of Urology, and continue to develop experiences and knowledge in the six (6) clinical competencies assigned last year. A. Participate in the preoperative evaluation and postoperative follow up of patients in the outpatient clinic setting. 1. Describe the essentials of office urology and be able to apply them in accordance within the framework of a hospital-based office setting. 2. Contrast the scope of care deliverable in a typical private office setting compared to that provided in the university- or hospital-based urology clinic with specific reference to: a. Office consultations b. Diagnostic procedures practical in the private vs. hospital-based office setting. c. Therapeutic modalities practical in the private vs. hospital-based office setting. d. Recognition of common urologic conditions seen in a typical private vs. hospital-based office setting. e. Sexual and fertility counseling. B. Participate in the inpatient care of hospitalized patients on the Urology Service. 1. Perform history and physical examinations on these inpatients and compare and discuss findings with fellow residents and attending physicians. 2. Make daily rounds on hospitalized patients, write progress notes, and discuss patients status with chief resident and supervising attending physicians. 3. Demonstrate a willingness and ability to function as a member of a team. a. Demonstrate mutual respect and cooperation among medical and paramedical personnel. b. Obtain and provide consultative services whenever appropriate. c. Demonstrate empathy, understanding, compassion, integrity, and honesty in the interactions with patients, family members, attending physicians, colleagues, and other medical and paramedical personnel. C. Participate as Assistant Surgeon or Surgeon (under the supervision of attending surgeon) in the operative management of urologic patients. D. Communicate daily with chief resident and attending faculty in selecting the cases from the operative schedule for participation in order to obtain maximal educational benefit from the variety of cases which may be available. II. Demonstrate expanded clinical experiences and increasing knowledge and competence in the following situations or in the performance of the following procedures: A. Demonstrate competence in performing the following outpatient clinic procedures: 1. Rigid and flexible cystourethroscopy; 2. Retrograde pyelography, retrograde and antegrade techniques to bypass ureteral obstruction and JJ stent placement; 3. Cold cup bladder biopsy; 4. Fulguration of minor bleeding (e.g., from cold cup biopsy sites) utilizing electrocautery under local anesthesia;

2 5. Retrograde urethrography and urethral dilation with sounds and balloons; 6. Local instillation therapy (e.g., BCG, DMSO, chemotherapy) including indications, complications, and management; 7. Oral and parenteral medication administration for active infection and / or prophylaxis; 8. Urethral and suprapubic catheter care; 9. Stomal care; 10. Wound care; 11. Vasectomy; 12. Neonatal circumcision; 13. Urodynamic evaluation, including CMG, flowmetry, VCUG, pressure / flow study, Valsalva Leak Point Pressure determination, and pelvic floor EMG measurement; a. Recognize the urodynamic patterns of: Detrusor Overactivity, Hypotonicity, Hyperreflexia, Autonomic Dysreflexia, Cystoparesis, Intrinsic Urethral Sphincter Deficiency, Stress Incontinence, Urge Incontinence, Mixed Incontinence, Detrusor External-Sphincter Dyssynergia (DESD), Functional Bladder Neck Obstruction, and Outlet Obstruction (from Prostate or USD); b. Discuss management options for the above voiding dysfunctions; c. Describe the indications for and technique to perform and interpret a Whitaker Perfusion Pressure Test; d. Describe the indications for and technique to perform and interpret a Bethanechol Supersensitivity (Lapides) Test; 14. Percutaneous suprapubic catheter placement; 15. Percutaneous nephrostomy tube placement; 16. Urologic applications of ultrasound, including: a. BladderScan PVR measurement and U/S evaluation of the bladder; b. Renal U/S and guidance for needle biopsy or access to collecting system of kidney; c. Small organ U/S, including penis, scrotum, testes, spermatic cord, and inguinal canals; d. Transrectal U/S (TRUS) for diagnosis of disorders of the Prostate, Seminal Vesicles, and Ejaculatory Duct; e. Digitally and TRUS-guided prostate needle biopsies; f. Color flow Doppler assessment of testicular blood flow in evaluating the acute scrotum; 17. Sclerotherapy for hydrocele; B. Demonstrate expanded knowledge of the causes and management of the following specific conditions: 1. Male Infertility a. Demonstrate an understanding of the hypothalamic-pituitary-gonadal axis, its endocrine control of testicular function, and abnormalities of hormone production which affect fertility; b. Describe the processes of spermatogenesis, sperm maturation, and sperm transport and storage; c. Demonstrate an understanding of the normal and abnormal anatomy and physiology of the male reproductive tract; d. Describe a rational, systematic approach to the clinical and laboratory evaluation of the infertile male; e. Select methodology for the clinical management (surgical and / or medical) of the infertile male and describe the anatomic and / or physiological basis for selection of specific treatment plans for the following conditions: (1) Endocrinopathies such as Kallman s Syndrome (hypogonadotrophic hypogonadism), primary testicular failure (hypergonadotrophic hypogonadism), and congenital adrenal hyperplasia; (2) Sperm maturation abnormalities, such as maturation arrest; 2

3 (3) Sperm transport abnormalities, such as absent vas, epididymal obstruction, or ejaculatory duct obstruction; (4) Ejaculatory dysfunction, such as absence of ejaculation or retrograde ejaculation; (5) Varicocele and oligospermia with stress pattern ; (6) Kleinfelter s Syndrome; f. Discuss ancillary methods of interdisciplinary management of male infertility including: (1) Artificial insemination (husband or donor) (2) Sperm processing and preservation techniques (3) Intrauterine insemination (4) In vitro fertilization (5) Gamete intra-fallopian transfer (6) Intracytoplasmic Injection of Sperm (ICSI) (7) Adoption 2. Urolithiasis a. Demonstrate a depth of knowledge of the etiology, pathophysiology, diagnosis, treatment and prevention of urolithiasis; b. Demonstrate an understanding of epidemiologic factors affecting stone formation, including: (1) Geographic differences in stone formation risks; (2) Incidence in relation to race, sex, age, and ethnic & climatic factors; (3) Effects of diet and fluid intake on occurrence; c. Describe the crystalline architecture of urinary calculi and discuss the theoretical factors affecting crystallization; (1) Crystallizable elements in urine; (2) Nucleation, growth, and aggregation of crystals; (3) Effects of ph on crystallization; (4) Other factors affecting crystallization, e.g., Citrate, Magnesium, Phosphate, and mucoprotein levels; (5) Concepts of stone size & shape and their effects on spontaneous passage rates; d. Demonstrate a knowledge of the effects of obstruction of the urinary tract from stones; (1) Describe changes in renal blood flow following acute ureteral obstruction; (2) Describe the changes in urine flow and intrarenal pressure with acute obstruction; (3) Describe the alteration in the above factors with chronic obstruction; e. Present a working classification of the types of metabolic stone disease and discuss their individual management; f. Demonstrate the ability to elicit a problem-directed history compatible with stone disease, including references to: (1) Pain patterns as an aid to localization; (2) Family history and personal (occupational) history; (3) Immobilization syndrome; (4) Diet and medications; (5) Fluid intake; (6) Previous stones and their management; g. Demonstrate an understanding of the information to be gained from urinalysis by discussing: (1) Appearance of typical crystals under the microscope; (2) Relationship of ph and specific gravity; (3) Possible significance of presence of bacteria; (4) 24-hour urinary excretion of creatinine, calcium, citrate, magnesium, phosphate, oxalate, and uric acid; 3

4 h. Select and evaluate results of specific blood tests to order, when evaluating patients with urolithiasis. i. Describe the value of crystallographic and chemical stone analysis. j. Demonstrate the ability and discuss limitations of various radiologic tests in diagnosing and differentiating by radiologic appearance alone the different types of urolithiasis: (1) Uric acid (2) Cystine (3) Milk of Calcium (4) Calcium oxalate (monohydrate and dihydrate forms) (5) Calcium phosphate (Apatite) (6) Infection stones (Struvite) k. Demonstrate the ability to select in a timely manner the appropriate therapy for a given patient and be able to defend the choice with reference to risks, benefits, and cost. (1) Dietary restriction and adjustment in fluid intake (2) Medications (a) Phosphates (b) Magnesium (c) Diuretics and sodium restriction (d) Citrate augmentation by medication or lemonade (e) Allopurinol and urine alkalinization (f) Chelating agents for cystine stones (e.g., penicillamine / cupramine or mucomyst ) (3) Genetic counseling when inheritable forms of stone disease are discovered (e.g., RTA) (4) Percutaneous nephrostolithotomy techniques (a) Access site selection (b) Techniques for tract dilation (e.g., high-pressure balloons vs. Amplatz dilators) (c) Techniques for stone fragmentation (e.g., EHL, U/S, Laser, or Pneumatic impactors) (d) Techniques for chemolysis (e) Relook nephrostolithotomy (5) Transurethral and ureteroscopic techniques discuss equipment, techniques, risks and benefits. (a) Describe the techniques for ureteral dilation (b) Describe the range of available endoscopes and discuss limitations and applications. (c) Be familiar with the working instruments for each of the above scopes and their usage. (d) Be familiar with the complications of ureteroscopic manipulation and their management. (6) Open surgical techniques discuss risks and benefits and describe individual techniques (a) Pyelolithotomy and Gil-Vernet Extended Pyelolithotomy (b) Coagulum pyelolithotomy (c) Nephrotomy with extraction (d) Anatrophic nephrolithotomy (e) Partial Nephrectomy (f) Simple Nephrectomy (7) Extracorporeal Shock Wave Lithotripsy (ESWL) (a) List the types of machines available sources of energy, methods of coupling, imaging / targeting systems, comparative costs, and relative advantages / disadvantages. 4

5 (b) List relative and absolute contraindications to ESWL management of certain stones. (c) Demonstrate ability to successfully image, target, and treat a patient on the ESWL unit. (d) Demonstrate a working knowledge of the control panel and optimal instrument settings for ESWL. (e) Demonstrate knowledge of safety limits for energy level and total # of shocks to be delivered per treatment episode for ureteral or renal stones. (f) Discuss the alterations in technique for pediatric or obese patients. (g) Discuss the physics of shockwave generation and mechanism of stone fragmentation. (h) Describe appearance of successfully treated stone. (i) Discuss pain management during lithotripsy. (j) Discuss post-eswl management. 3. Female Urology A. Demonstrate the ability to evaluate, diagnose and treat a wide variety of lower urinary tract and vaginal conditions occurring in the female including: 1. Genuine stress urinary incontinence 2. Urge incontinence 3. Intrinsic sphincter deficiency 4. Vesicovaginal fistula 5. Neuropathic dysfunctions of the lower urinary tracts 6. Interstitial cystitis 7. Vaginal, uterine, and rectal prolapse 8. Endometriosis and its effects on the urinary tract 9. Vaginitis and female urethral syndrome 10. Urinary tract infection 11. Urinary obstruction anatomic and functional 12. Urethral prolapse 13. Urethral diverticulum 14. Urethral caruncle B. Demonstrate the ability to choose, perform and/or recommend appropriate therapies from the list below, for the above conditions. 1. Kegel pelvic floor exercises 2. Pharmacological and hormonal therapy when indicated 3. Anterior colporrhaphy (Kelly plication) / posterior colporrhaphy 4. MMK / Burch urethropexy 5. Transvaginal needle suspensions 6. Pubovaginal sling procedures 7. Urethrolysis (take-down of obstructing urethral suspension operations) 8. Periurethral injection therapy 9. Artificial Urinary Sphincter Implantation 10. Sacral nerve stimulation 11. Bladder augmentation (enterocystoplasty) 12. Self Intermittent Catheterization 13. Vesicostomy and catheterizable stomas (Mitrofanoff Procedure) 14. Supravesical diversion, including conduits, continent reservoirs, and neobladders 15. Transvaginal and transabdominal techniques for vesicovaginal fistula repairs 4. Obstructive uropathy A. List and discuss the causes of obstructive uropathy (congenital, iatrogenic, and acquired) and discuss their pathophysiology; 5

6 B. Recognize the clinical signs and symptoms C. Select appropriate diagnostic tests to define the cause be able to defend the choice of studies and state the advantages, hazards, and complications of the studies selected. D. Presented with an example of an obstructed condition, discuss a solution for a patient with obstructive uropathy. 1). Demonstrate an understanding of the natural history of the lesion and how the outcome can be most favorably altered. 2) Discuss the available diagnostic and therapeutic modalities with consideration given to the advantages, hazards, and complications of each treatment indicated below: a. Surgical repair or correction of obstruction b. Minimally invasive surgical alternative (e.g., endourological management) c. Temporary and permanent diversion with or without tubes or catheters. d. Pharmacological management 3) Discuss the acute and chronic effects of urinary obstruction upon the structure and function of the various portions of the urinary tract and comment on the relationship of the degree and duration of obstruction to function and restoration of function. 5. Diagnosis and endoscopic management of bladder cancer. A. Demonstrate the ability to diagnose a patient with cancer of the bladder and list the various types of bladder abnormality. 1) TCC and CIS 2) Adenocarcinoma 3) Squamous Cell Ca 4) Cystitis cystica and glandularis 5) Squamous metaplasia 6) Malakoplakia 7) Sarcoma B. Discuss epidemiological aspects of bladder cancer and list some common risk factors. 1) Family history 2) Cigarette smoking direct and secondary smoke inhalation 3) Chemical carcinogen exposure e.g., alanine dyes or tryptophan or its metabolites 4) Chemotherapy e.g., cytoxan (cyclophosphamide) 5) Chronic inflammation e.g., stones, infection, schistosomiasis C. Identify and differentiate the various forms of bladder cancer and distinguish them from other entities that may mimic bladder cancer. D. Describe the TNM classification for staging of bladder cancer. E. Demonstrate the ability to elicit a history of the possible presence of bladder cancer. F. Demonstrate the ability to recognize by endoscopy (or 35 mm slides) of typical bladder cancer. G. Describe staging techniques physical exam, radiologic and pathologic H. Discuss the endoscopic management of clinically superficial TCC I. Discuss the endoscopic management of clinically locally invasive TCC J. Discuss the management of metastatic TCC K. Discuss the roles of topical chemotherapy and immunotherapy in management of TCC. L. Discuss the concepts of induction and maintenance and describe a typical regimen for BCG treatments in a patient who has recently been diagnosed as having recurrent superficial (Ta or T1), grade 2 TCC. M. Discuss the rationale and changing trends in standard of care for the use of various forms of radiation therapy alone or in conjunction with surgery and/or chemotherapy. N. Discuss various types of supravesical urinary diversion and considerations of their suitability in the context of particular disease stage and patient condition and motivation. 6

7 O. Discuss the rationale for use of systemic chemotherapy in the treatment of regional and metastatic TCC and list some of the more active agents. 6. Diagnosis and management of benign prostatic hyperplasia (BPH). A. Discuss the incidence / prevalence of BPH B. Discuss its pathophysiology with reference to the following: 1) Androgen dependence and the role of DHT and 5 alpha reductase enzyme explain mechanism of action of finasteride 2) Stromal and epithelial cell interaction and proliferation 3) Alpha adrenergic mediated smooth muscle tone in the prostate and bladder neck explain mechanism of action of alpha 1 blockers (Cardura and Hytrin) and the newer super selective alpha-1-c blockers (tamsulosin or Flomax). C. Demonstrate competency in assessing a patient s lower urinary tract symptoms (LUTS) and determining their AUA Symptom Score and their symptoms effect on quality of life ( bothersomeness score). D. List the specific indications for upper tract imaging and/or endoscopy in the evaluation of a man with moderate LUTS compatible with BPH. E. Describe the possible usefulness of uroflow studies, pressure/flow studies, CMG, PVR determinations, serum creatinine determinations, and urinalysis in evaluating BPH. F. Discuss the appropriateness of surgical intervention in men with serious complications of BPH, including urinary retention, intractable hematuria, bladder stones, and renal failure secondary to BPH. G. Discuss various treatment options and their relative risks, benefits, costs, and side effects. H. Discuss indications and demonstrate technical ability in preoperative, operative, and postoperative management of open subtotal prostatectomy for BPH. I. Discuss indications and demonstrate technical ability in performance of endoscopic management of BPH. 1) Demonstrate competence in the procedures: TURP and TUIP - discuss their relative indications and results. 2) Demonstrate knowledge of and ability to manage intraoperative and postoperative complications of TURP. 3) Be able to discuss the principles of electrocautery and its risks and benefits: J. Discuss the rationale, indications, relative effectiveness, and complications of the newer minimally invasive therapies for BPH, including laser prostatectomy (or ablation) [using contact, noncontact, or interstitial laser applications], balloon dilation, hyperthermia, thermal coagulation therapies, stents, and intraprostatic injection of absolute alcohol. K. Discuss the appropriate follow up of patients undergoing watchful waiting, as well as those on medical therapy and those having received one or more of the minimally invasive surgical alternatives. 7. Demonstrate an understanding of the neurology and muscle physiology of the bladder and urethral and their relationship to male continence and incontinence. A. List the types of male urinary incontinence including: overflow, urge, total, stress, functional, and enuretic. B. Discuss the history in differentiating the various etiologies including: congenital anomalies, neuropathic bladder dysfunction related to disease or injury to the CNS or peripheral nerves, trauma to sphincter, iatrogenic (including post-surgical), neoplasm, stricture, radiation induced, and psychogenic. 8. Describe the anatomic and physiological causes and effects of renal vascular hypertension. A. Provide a differential diagnosis and discuss management of the various types. B. Select and interpret appropriate diagnostic studies and discuss treatment recommendations and results. 1) Medical antihypertensive management 7

8 2) Percutaneous transluminal angioplasty (PTA) 3) Surgery including: bypass operations / revascularization / nephrectomy (or partial nephrectomy), endarterectomy, aneurysmectomy, and autotransplantation 9. Identify the signs and symptoms of urogenital trauma, clinically select the appropriate diagnostic studies, interpret them correctly, and then manage cases of trauma to the upper and lower urinary tract. 10. Discuss management of blunt and penetrating injuries to the kidney, ureter, bladder, urethra, and external genitalia. Discuss the results and complications of each course of treatment selected. 11. Demonstrate knowledge of cell and molecular biology pertaining to urologic diseases. A. Describe the mechanism of DNA storage, RNA transcription, and mrna transcription and translation. B. Identify the critical steps involved in the selective expression of eukaryotic cells. C. Demonstrate an awareness of the molecules involved in hormone action and cellular signal transduction, e.g., growth factors that mediate cellular function and reproduction. D. Discuss and provide examples of specific molecular defects associated with GU tumors and certain benign urological diseases. E. Identify specific molecular defects associated with various GU malignancies and discuss processes of gene amplification, gene deletion, gene rearrangement, and integrated viral gene activity. F. Discuss and provide specific examples of the classes of gene products associated with oncogenesis of the GU tract, including oncogenes, tumor suppressor genes, and cell death (apoptosis) suppressor and initiator genes. G. Discuss the molecular defects associated with benign GU diseases, e.g., papillomatosis and renal cystic disease. 12. Through supervised daily medical practice and through participation in clinical competencybased evaluation exercises, you should continue to acquire the necessary skills to achieve competence in the six (6) medical competencies: Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Professionalism, Practice-Based Learning and Improvement, and Systems-Based Practice. I have reviewed with the resident his / her progress toward accomplishment of the stated goals and objectives for the current level of training and have provided individual feedback evaluation. Signed: Date: Program Director Note to Resident: At the end of each training year you will also be asked to self-evaluate your personal attainment of each educational goal and objective. You will indicate your perception of accomplishment of each stated goal and objective by marking in the margin alongside each the following coded response: + indicates satisfactory accomplishment of this particular goal or objective. indicates exposure to, but incomplete acquisition of, knowledge or experience.** - indicates perceived deficiency in knowledge or clinical experience in this area.** ** You are expected to carry these goals & objectives over to subsequent years. I have reviewed with the Program Director my understanding of educational goals and objectives expected during this year/level of training (prior to beginning this year), and have received individual feedback regarding my degree of accomplishment of the stated goals and objectives 8

9 including acquisition of competency in the six designated competencies (at the completion of this year). Signed: Date: Urology Resident 9